He explained that it is important to know the anatomy in the area of the
operation and to be gentle so as to prevent as much trauma and bleeding as
possible.

Bleeding makes it hard for a surgeon to see what he's doing. When a
surgeon has a good view, he can be precise, meticulous and dissect in exactly
the right place.

"Most important is not to injure the muscle fibers of the external
sphincter," Dr. Catalona said. "I call it the 'no touch technique'. Do your
best to leave them the way God made them."

"The fear far outweighs the reality."

He explained that temporary incontinence is usually (although not always)
a component of post surgery recovery. Bladder control starts improving soon
after the catheter is removed, but it could take six to 18 months for the
complete return of continence in some patients. After that time period,
little improvement is expected.

While incontinence seems to have several definitions, Dr. Catalona uses
only one: "If men have to wear any kind of protection at all, they are
incontinent."

Using that definition, five and a half percent of his patients have a very
mild incontinence 18 months after surgery and one and a half percent have
severe incontinence. Age figures strongly into these outcomes and so does
the fact that some men go into the surgery with previous incontinence.

Understanding the connection of a radical prostatectomy to continence, and
to the temporary incontinence after the operation, is a matter of
understanding the anatomy of the area around the prostate and the procedures
during the operation.

The prostate is a plum sized gland that lies below the bladder and
inbetween the bladder and the urethra. The urethra, which carries the urine
out the body, starts at the bladder, runs through the prostate and then
continues through the penis.

"When a surgeon cuts out the prostate, a gap is created between the
bladder and the urethra. The bladder must be pulled down and the urethra
pulled up so that the two can be surgically reconnected," Dr. Catalona
explained.

"Frequent urination is normal after a radical
prostatectomy."

The larger the prostate the bigger the gap and sometimes the more
difficult to reconnect the bladder and the urethra. In addition, the
internal sphincter muscle, the muscle that involuntarily controls bladder
output, is removed with the prostate.

After the operation, men who had three layers for holding back urine  the
internal sphincter muscle, the prostate lobes pressing against each other,
and an external sphincter muscle  have only one, the external sphincter.

"The external sphincter can do all the necessary work to hold in the
urine, but it has to be strong. That's why the Kegel exercises, both before
and after surgery, are so important," Dr. Catalona said.

He explained why procedures during the surgical removal of the prostate
cause temporary incontinence and how time and the healing process usually fix
the situation.

The bladder and the urethra must be connected to each other but if they
were just sewn together, postoperative swelling of the tisues would close the
opening for the urine to pass through. Temporarily, they need a stent to
preserve the opening, and that stent is the catheter.

The bladder is always being emptied by the catheter. The bladder isn't
holding urine and therefore doesn't expand as long as the catheter is in
place. When the catheter is removed, the bladder is a shrunken version of
itself.

Dr. Catalona knows that men are anxious to have the catheter removed, but
most often, they leave the hospital with a catheter in place and it remains
for one to two weeks, rarely more. The time frame for removing the catheter
depends upon how nicely the urethra and bladder come together. If it's with
little tension and little stretching, the catheter can be removed sooner.

Also, when the bladder is exposed during the surgery, it takes some
physical blows and it swells, just as other parts of your body swell when
they take a hit.

"Frequent urination is normal after a radical prostatectomy," Dr. Catalona
said. "The main cause is that the bladder wall is swollen and thickened and
irritable. Normally, the bladder wall is thin and very elastic and maintains
a low pressure until it has stored 8 to 10 ounces of urine. After surgery,
the swollen bladder does not store much urine at a low pressure. As soon as
it starts to fill, the pressure goes up and the patient feels the need to
urinate. In the great majority of cases, this gradually improves with time,
but it can take more than a year in some cases."

Later in the healing process, those scars can cause difficulties for the
bladder because they make it difficult for the bladder to expand as it
should. The scars increase the time it takes for the bladder to expand and
therefore increase the time to return to continence.

"Also, sometimes after surgery, the patient can get a stricture at the
point where the urethra and bladder are connected. Then, after the catheter
is removed, the already irritated bladder is trying to force out the urine
through a pinpoint," Dr. Catalona said.

Often, symptoms are the worst at night.

"After surgery, some fluid that is retained in the lower half of your body
during the day gets redistributed at night and is excreted by the kidneys at
night," Dr. Catalona explained.

Eventually, most damage to the bladder and the urethra heal, but it takes
time and the improvement in continence is gradual, with complete recovery
taking from six to 18 months.

"The most common cause of incontinence after a radical prostatectomy is a
weak external sphincter muscle," Dr. Catalona said. "The surgeon has to try
his best not to injure it and to preserve its length.

"Most important is to protect muscle fibers of
external sphincter."

A recent study
at Memorial Sloan Kettering connected the length of the sphincter before
surgery with how quickly continence returned after surgery.

The external sphincter muscle squeezes the urethra, enabling it to retain
the urine until the sphincter releases its hold. Its action is both
involuntary and voluntary. The effectiveness of the sphincter is a
combination of length and strength. The longer it is, the more efficient it
is. The stronger it is, the more effective it is.

Patients can not control how long their sphincter muscle is, but they can
contribute to how strong it is by doing Kegel exercises as recommended by
their doctors both before and after surgery.

"Kegel exercises are so important."

"But men aren't always as compliant as they should be," Dr. Catalona
said.

Also, he added that it doesnt help to do Kegel exercises improperly.
Sometimes, men are told to squeeze their buttocks together and that
instruction is incorrect.

In describing how to do Kegel exercises, Dr. Catalona recommends to his
patients that they imagine they are in the bathroom urinating and someone
opens the door. They would cut off their stream and hold it for a second or
two.

After surgery and after removal of the catheter, he suggests doing this
exercise in sets of 10, four times a day  before breakfast, lunch, dinner
and bedtime.

When patients do urinate, he tells them to stop in midstream once or
twice. Then they will know they are exercising the correct muscle.

"If as men begin to regain continence, they leak in the evening, it's
caused by fatigue," Dr. Catalona said. "Sometimes it happens after drinking
a glass of wine and that's because the alcohol has caused the muscle to
relax."

Overexercising does not help. In fact, it can slow down the healing and
strengthening process.

"The idea that if 10 are good, 100 are better and a 1000 even better
doesn't work. The sphincter musce is recuperating after surgery and it wil
get fatigued if the exercises are repeated too many times," Dr. Catalona
said.

Age is a definite factor in return of continence, most likely because, as
with other muscles, the condition of the sphincter muscle deteriorates with
age.

Also, Dr. Catalona said that about 30% of his patients over 50 years old
have some version of bladder instablility or stress incontinence before the
operation.

"Men can not expect to have better control of their bladders after the
operation than they did before," he said.

Few options are available for men who are mildly incontinent, but in
outcome studies measuring function and bother, the small percentage of men in
this category don't report high levels of concern.

For the one and one-half percent of men who have severe incontinence,
correction is possible with the surgical implant of an artifical urinary
sphincter or a urethral sling procedure.

"The operations do work," Dr. Catalona said. "Most patients who have the
procedure improve almost immediately. I'm not sure why more men with the
severe incontinence don't request it. Perhaps, they have had enough of
surgery and are relunctant to go through the experience again."

Most important for patients to know is that the very nature of a radical
prostatectomy causes a temporary incontinence, but in most cases, bladder
control starts to improve after the catheter is removed and continence
returns within six to 18 months.

Proper surgical training and experience are key factors in the success of
regaining continence after RRP surgery. Dr. Catalona does extensive
follow-up on patients, and as part of that follow-up, men are asked if they
would be willing to share their experiences with other patients.